Provider Demographics
NPI:1992706840
Name:AMBULATORY SURGERY CENTER OF BURLEY, LLC
Entity type:Organization
Organization Name:AMBULATORY SURGERY CENTER OF BURLEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-677-8888
Mailing Address - Street 1:1344 HILAND AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-1564
Mailing Address - Country:US
Mailing Address - Phone:208-677-8888
Mailing Address - Fax:208-675-5833
Practice Address - Street 1:1344 HILAND AVE
Practice Address - Street 2:SUITE E
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-677-8888
Practice Address - Fax:208-678-5833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805534000Medicaid
ID24973 000010005417OtherBLUE SHIELD
ID03822OtherBLUE CROSS
ID805534000Medicaid